Health Informatics in an Accountable Care Age

The Centers for Medicare and Medicaid Services (CMS) recently released the long awaited rules and regulations for Accountable Care Organizations.  CMS touts this new patient care paradigm as a shared savings model.  However, Providers must clearly take on the risk of payment penalties if they fail to meet all the measures.  CMS designed the ACO to accomplish 3 goals; better care for individuals, better population health and reduced costs to CMS. [i]  .  If the benchmarks are met then the physician will be paid additional revenue for his/her application of medical knowledge and positive outcomes. This is something most physicians want instead of the current system of “chasing” one more fee for service patient visit.

 Each ACO will be required to provide medical care to a minimum of 5000 Medicare patients.  To add a little uncertainty to an already monstrous undertaking it is at the end of the year that Medicare will choose which of these patients will be accessed for proper receipt of care.  In essence all 5000 plus patients will have to cared for at the highest standards and for the lowest costs.  As you read through these goals you will see that it will be virtually impossible to accomplish the delivery of patient care and appropriate documentation needed without full emersion into Health Care informatics. 

Better care for individuals will be determined by measurable improvements in patient safety, treatment effectiveness, patient-centeredness, timeliness of care delivery, efficiency of operations, and equity of care.  There are 65 different performance measures over 5 “domains”.  Many of these measures like care coordination across the continuum of health care providers through interfaced information systems are tied directly to the HITECH Meaningful use requirements.  Other performance measures necessitate the use of an EHR if for no other reason than the measures are so extensive that a physician or nurse would never be able to consistently (unerringly???) remember the criteria without programmed alerts.

 Diabetic care has 10 different measures and congestive heart failure (CHF) has 7 measures of accountability.  A physician will need electronic alerts to ensure patients are scheduled on a Best Practice schedule.  If the patient doesn’t show up for their appointment then an alert will be needed to let the physician know to call the patient.  The call will need to be documented with an electronic time and date stamp to validate contact/attempted contact.   Medications and diagnostic tests must be ordered through an eRx component. The tests have to be tracked for completion and the medications trailed to ensure they are purchased and taken as directed. If refills aren’t called in on schedule then…you guessed it…an alert needs to go off.  All of this must come with a cross reference medication and diagnostic contraindication alert.  A decision support mechanism will be essential to take into account patient multi morbidity and what pathways of Best Practice to follow to obtain the optimum treatment for the lowest cost.  If this is sounding way too complicated just wait until you hear what needs to be done to achieve better population health while reducing costs. Well, for your mental health and mine I won’t cover those goals in detail.

More importantly I’ll highlight why the coming of the ACO is so important in the evolution of EHRs and the discipline of Health Care Informatics.  Incentivizing healthcare providers and in many ways the general public to start utilizing EHRs is a necessity.  This transition to electronic supported healthcare is going to be very difficult for most people and would happen slowly or possibly not at all otherwise.  The ACO regulations lay out such essential yet complex goals for healthcare that the people developing and supporting EHRs must advance far beyond their capabilities of today in order to effectively address future needs.  Ease of use to include advanced user customization, diverse yet easily understandable decision support capabilities, fluid interoperability, sophisticated speech recognition and   lower systems costs all preclude early adoption of most EHR systems.   Answers to these problems will only emerge as more people use the systems, discover their flaws or shortcomings and develop the comprehensive solutions.  The ACO provides this motivation and momentum in the discipline of Health Care Informatics. 

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[i]DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services 42 CFR Part 425 [CMS-1345-P] RIN 0938-AQ22 Medicare Program; Medicare Shared Savings Program: Accountable Care http://www.ftc.gov/opp/aco/cms-proposedrule.PDF

Are RACs Misusing Healthcare Informatics When Auditing Health Records?

Created to discover and resolve improper Medicare payments, Recovery Audit Contractors (RACs) have become what some in the healthcare industry are calling “High Tech Bounty Hunters”[i].  They were instituted in section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), and recovered approximately $1 billion between 2005 and 2008.  Due to these astounding collections  Section 302 of the Tax Relief and Health Care Act of 2006 made the RAC Program permanent and required the Secretary to expand the program to all 50 states by no later than 2010.[ii] 

There have been 2 key components to the program’s success.  First is the payment structure to the RACs.   A powerful motivator is the substantial incentive payouts of up to 12.5% of the monies recovered. That’s $125,000,000 over 3 years, not bad.   The second key component is their means of identifying potential overpayments.  

The RACs have proprietary informatics software that regularly updates from Medicare rules and regulations, medical practice standards, and coding and billing policies.  In addition they include specific services identified for likely overpayment by the OIG, the GAO and Comprehensive Error Rate Testing (CERT) findings.  From this up to-the-minute regulation, terminology and medical best practices information, the RAC will identify those medical diagnoses and treatments in which claims have a high probability to be overpaid (or underpaid but finding these claims don’t pay out as much)  in their region. These targeted diagnoses and patient treatments and services are then entered into the RAC database search engine or “scrubber” and they are ready for the “hunt” (I mean ready to help America collect overpayments and reduce its healthcare expenses).    

Talk about an electronic full court press that is woefully one-sided! Healthcare providers have to consider all aspects of the healthcare process and quite often without the benefit of computerized assistance.  First and foremost they have the responsibility of hands on care of patients with multi-morbidities through continual enhancement and application of medical knowledge.   Next they have to learn and comply with an assortment of regulations, billing policies and procedures.  Extensive and changing documentation terminology has to be internalized to ensure immediate and consistent usage.  Finally they have the complex task of managing their Practices.

 In contrast, RACs have a single focus of reviewing medical billing and care documentation with exceptionally effective proprietary software. This is augmented by medically trained people when needed. Such as when there is no definitive Medicare rule for the healthcare Providers to follow or when nothing has been found but the RAC still thinks there is a high probability that an overpayment exists.  Sounds fair so far doesn’t it? But, it gets better.   Over a 45 day period RACs can request up to 500 records (depending on the size of the healthcare provider) going back 3 years.  Once the RACs have the billing and any electronic data they mine/scrub it for inconsistencies and require repayment for any discrepancy.  An alternate interpretation of terminology or understanding of “Best Practices” between (multiple) healthcare providers who provided medical care to the same patient causes everyone to be identified as overpaid and potentially fraudulent.  One physician codes as mild and the other codes as moderate and now 3 years later both of them and the hospital where the patient was treated have to repay at least some if not all of their reimbursement. (The patient got better by the way and tells everyone about the great care that saved his life.) .  

“Like shooting fish in a barrel” comes to mind. The RAC earns 12.5% of the recovery just by employing a software program that can detect minute differences in complex medical documentation and subsequent billing. Repayment is immediate and appeals can take years to resolve.   No wonder RACs are being referred to as High Tech Bounty Hunters.   A misuse of healthcare informatics?  Medicare and the RACs don’t think so but ask any healthcare provider who has gone through this process and you will get a resounding YES!!! 

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[i]FierceHealthIT, weekly news for Health IT Leaders, March 29, 2010:   http://www.fiercehealthit.com/story/cms-fight-medicare-medicaid-fraud-high-tech-bounty-hunters/2010-03-29

[ii] CMS; RAC Overview; http://www.cms.gov/RAC/01_Overview.asp

From "The Cloud" to "The Ether"

In today's world of Health Care Informatics nothing seems more vital than creating and implementing “The Cloud".  This synthesis of all things digital that can transform data from any system and transport it to any other system in an accurate, usable format is intended to be the focal point of Health Information Exchange.  Because of the HITECH Act and the subsequent health care push to divest itself of paper and go fully electronic many multinational companies see a tremendous new business opportunity in health care.  Microsoft and IBM immediately come to mind but others like Google, AT&T and Verizon have quickly followed.  This evolution makes sense because these are the companies at the forefront of making communications and information transfer easy and always accessible for the masses.  So what is their role in developing “The Cloud” and why do we need to progress into something much more comprehensive yet uncomplicated for the end user?

The theory behind the Cloud is that it can (or will be able to) accept electronic information from unlimited systems, hold the information in storage and when called upon, instantly and accurately deliver it to either the originator or a completely different system.  The goal is to speed the acceptance of an electronic health care age by making all systems fully interoperable regardless of structure and design.  In order to do this the programmers must break each component of the health care process down to its essence.  A lab panel will not be sent to the Cloud as 25 interlocked pieces of information on a form or template that has to be retrieved in this exact same format in order for the information to be readable and accurate.  Instead the 25 lab values will be formatted individually so that the value for red blood cell count will be separate and distinct from the value for white blood cell count. This will allow the receiver of the information to choose to see only 1 value from that panel of tests or to see any combination of values.  The report the receiver sees can now be configured into any format that meets his or her needs.  The companies mentioned above and countless others are dedicating billions (more?) of dollars towards the resources needed to accomplish this task.  Creating and implementing these Clouds will go a long way towards advancing the acceptance and use of Electronic Health Records.  However this still does not address the heart of the problem for the end user of the EHR.

 The electronic consumerism brought to us by Microsoft, AT&T and others builds on our individual likes, needs and wants of how we will use the products.  Complete customization endearing us to ease of use and inherent familiarity are becoming the norm.  We have individual cell phone rings, point of sale devices that easily recognizes keypad number input or your signature, voice recognition software and even a GPS that combines coordinates with real time traffic information and gives you directions in whatever language you choose. Now with genetics, health care is starting to provide individualized health screening and drug therapy.   Talk about customization to what works for each individual!!!  This is what is missing in the current EHRs that would facilitate adoption more than anything else.

Early scientists and businessmen like Thomas Edison, Nikola Tesla and Napoleon Hill spoke and wrote often about a “universal connecting substance or energy” called Ether. Per these great minds, Ether permeated everything and directed energy including electrical current, and even thought waves from a sender to a particular receiver.  This abstract notion of Ether was used to explain events such as how Egyptians and Mayans, while continents apart, could assimilate diverse groupings of information into intelligent data/facts and build almost identical pyramid temples that functioned as calendars and repositories of mathematical formulas.  I believe the large corporations are missing their chance to innovate what they are learning while constructing “The Cloud” into a seamlessly customizable integrated EHR system that could become “The Ether”. 

Once they have mapped each item or process of health care so precisely that it can be separated from an existing panel of data, stored as an individual piece of information and later retrieved by any system in an accurate, useful manor then they can develop this into the ultimately customizable EHR.  With all of the components of health care electronically regimented and organized in such a way then surely a copy and paste system could be utilized to build the “perfect” EHR. Since the information could be easily stored and retrieved by any system configuration the screens of physician partners and their staff could look completely different.  Building on existing technology it would be up to the user if they typed, wrote, spoke or used any of these in combination to input the data.  The Laboratory file tab could be on the left of the page for one user and the bottom right for another. Each user could build their own diagnostic imaging or lab test panels for what was most important to them and it not hinder how another provider could view that information at a later time.   

Primary barriers to EHR adoption by the people trying to use the systems are the lack of familiarity and insufficient ease of use.  Current societal conditioning exacerbates this because so many other things in our lives have evolved to becoming almost fully customizable.  While building “The Cloud” the Multinational companies need to be looking to the next great improvement. This moves us away from choosing a system that is acceptable for most of the people involved to each person essentially creating his or her own system.   “The Ether” could be the design that fully integrates the end user with the Electronic Health Record. 

 

The Bumps, Bruises and Rewards of Transitioning to the Electronic Age of Health Care.

Three years ago I started the exciting, stressful yet exhilarating experience of  working with a hospital and loosely organized group of physicians to delve into the electronic age of healthcare. Our stretch goal is to become completely paperless. We have had our setbacks,  failures and thankfully our successes.  After three years we continually learn, innovate and we already plan to enhance what we know with a system change. We started out thinking the evolution to EMR/EHR would be a bit painful but then we would "know it" and we could relax with our accomplishment.  But, we now know enough to know that in the electronic age of healthcare change will not end, it will get faster.

We started our initial assessment of EMR Vendors by vetting about 75-80 companies. This was before the standardization that happened at the end of 2010 and continues today.  It was difficult to determine who could provide the necessary services.  Every company's presentation made their product seem adaptable to become anything we needed.  Thanks to a lengthy, highly specific RFP we narrowed the choice and made our decision.  About a week later the two front runners merged and within about two months this conglomerate had obtained a couple of the other smaller companies.  Change was already happening fast and it made us realize what a ride this transition would be.  Unfortunately the promises of total adaptability with cut and paste forms, easily convertible files and point and click processes were not a reality.  They met their contract requirements by providing the support for us to get where we needed but this was a slow and painful process for the Providers, Administration and the EMR/EHR Vendor. What we found out was that in those early stages of EHR adoption the IT companies didn't really know how a physician's practice operated, most of the physicians were more set in their ways than they realized ( and these were the Early Adopters!) and productivity and revenue plummeted.

We have made adjustments by  training...training...training, and increasing bandwidth to significant levels over "required". We standardized our own forms, process and procedures, expanded our IT department both in knowledge and in staffing, and recruited physicians with EHR knowledge to assist those still learning. As I alluded to earlier we are looking at changing our EHR in the near future to take advantage of recent advancements within the industry. 

Our productivity and revenue now surpass where we were with our paper system. We are not paperless but have made significant strides. At most if not all conferences we can see that we are significantly ahead of most other healthcare systems in the electronic age transition.  We are leaders in the healthcare field because we were willing to take the step forward, withstand the bumps and bruises and enjoy the rewards of doing what we knew we had to do to be better Providers to our community.